Localized Pigmented Villonodular Synovitis of the knee: an arthroscopic treatment

Abstracts

Os autores apresentam sete pacientes portadores de Sinovite Vilonodular Pigmentada Localizada (SVNPL) tratados através de ressecção artroscópica, entre o período de junho de 1994 e Outubro de 2001. À avaliação inicial, os sintomas variaram desde dor difusa, até um aumento do volume localizado, com ou sem bloqueio mecânico do movimento articular. A ressonância magnética auxiliou na localização das lesões e no controle pós-operatório. O diagnóstico foi confirmado pelo exame anatomo-patológico. Na última avaliação nenhum dos pacientes apresentou recidivas dos sintomas do pré-operatório, nem no exame por imagem com ressonância magnética. Apesar da casuística pequena, própria dessa afecção, os autores acreditam que a excisão artroscópica da SVNPL é um método eficaz, de baixa morbidade, proporciona remissão dos sintomas e com pouca possibilidade de recidivas.

Joelho; Sinovite vilonodular pigmentada; Artroscopia

ORIGINAL ARTICLE

Localized Pigmented Villonodular Synovitis of the knee: an arthroscopic treatment

Arnaldo José Hernandez^I; Gilberto Luiz Camanho^II; Marcos Henrique Laraya^III; Edimar Fávaro^IV; Maurício Martinelli Filho^V

^IFull Professor at the Medical School, University of São Paulo. Head of the Knee Surgery Group

^IIFull Professor at the Medical School, University of São Paulo. Head of the Discipline of Specialized Orthopaedics

^IIIMaster in Orthopaedics and Traumatology at the Federal University of São Paulo. Ex-fellow of the Knee Surgery Group

^IVEx-fellow of the Knee Surgery Group

^VEx-Resident

^{Correspondence}

SUMMARY

The authors present a series of seven case reports of Localized Pigmented Villonodular Synovitis (LPVNS) treated by arthroscopy resection between June of 1994 and October of 2001.

At the baseline evaluation, symptoms ranged from diffuse pain to localized swelling of the knee, with or without mechanical blockage of the joint. Magnetic Resonance helped in localizing the lesion and in the follow up evaluation. Diagnosis was confirmed through anatomicopathological examination.

By the end point evaluation, none of the patients presented recurrence of the pre-operative symptoms referred before. Magnetic resonance imaging also showed absence of symptoms.

Despite of the small number of patients, typical of this affection, the authors believe that arthroscopic excision of the LPVNS is an effective method, with low morbidity, providing remission of the symptoms and a low recurrence potential.

Keywords: Knee; Pigmented villonodular synovitis; Arthroscopy.

INTRODUCTION

Pigmented Villonodular Synovitis (PVNS) is a rare proliferative, benign lesion, of unknown origin, typically monoarticular, especially affecting the knee during the third and fourth decades of life^(1,2), being uncommon in other joints, such as the ankle⁽³⁾. Its yearly incidence, according to Myers⁽⁴⁾ is 1.8/1000000 patients. Histological features of such lesions have first been unified by Jaffe et al.⁽⁵⁾ in 1941, but it is believed that a nodular lesion involving the synovial membrane of the flexor tendon, described by Chassaignac in 1852, was a PVNS⁽⁶⁾. In 1976, Granowitz e Mankin⁽⁷⁾ proposed a clinical classification of the PVNS according to the joint synovial membrane involvement, characterizing it as diffuse form and localized form. Both kinds can be found in the knee, with the diffuse form being the most common one.

The localized form is characterized by a nodular formation, which can be sessile or, more frequently, pedunculated. It is localized especially at the meniscus-capsular union, intercondylar region, tibial eminence, lateral recess and, occasionally, at the HOFFA fat^(1,5,8,9).

In this study, we present four case reports (four knees) with Localized Pigmented Villonodular Synovitis (LPVNS) treated with arthroscopic resection, intending to call the attention to its diagnosis and to check the results achieved with the treatment of this rare lesion.

MATERIALS AND METHODS

Seven patients (seven knees) presenting LPVNS have been submitted to surgery between June 1994 and October 2001, through arthroscopic section of the lesion. Ages ranged from 5 to 40 years old, with an average of 26.1 years. Four patients were males and three were females. Average follow-up time was 36.1 months (12 — 74 months). On Table 1, patients with their respective order numbers, ages, genders, follow-up periods and lesion sites are listed.

Symptoms ranged from diffuse pain, with or without significant swelling of the joint, to a localized volume increase, with or without mechanical blockage of the range of motion. Radiographs of all individuals showed no changes. Magnetic resonance imaging helped in localizing lesions (Figures 1A and 1B), which has also been used as a postoperative control. Surgical technique involved the use of marginal resection of the lesion through arthroscopy in all cases, with diagnosis confirmed by anatomicopathological examination postoperatively.

The outcomes have been evaluated according to clinical examination and magnetic resonance imaging.

RESULTS

By the clinical examination, no patient presented recurrence of signs and symptoms reported before surgery until the end-point follow-up visit. Magnetic resonance imaging (Figures 2 A and 2B) presented no evidences of lesion recurrence in all subjects.

DISCUSSION

In 1941, Jaffe⁽⁵⁾ was the first to unify the multiple manifestation of this disease and to describe its histological characteristics, proposing the name PVNS; however, many other names for such condition still exist in literature, such as, for example, giant-cell tumor of the tendon sheath and synovial xanthoma⁽¹⁰⁾.

Differently from literature reports, one of our cases was at the first decade of life. However, due to the small sample, conclusions towards this matter are not possible.

The etiopathogenesis of the PVNS remains unclear. Some authors suggest that the development of this disease can be a result of a lipid metabolism change, inflammation, or a benign neoplastic process⁽⁷⁾. The possibility of trauma-induced PVNS has also been reported^(4,10,11).

Clinical diagnosis of the PVNS is difficult, since symptoms are non-specific, and can include: diffuse pain, edema, palpable tumor, motion limitation, and knee joint restraint^(1,8). Joint swelling, whenever present, is usually hemorrhagic with a dark brown color⁽⁹⁾. We think that it's worthy to mention the study by Van Meter⁽¹²⁾, which emphasizes the importance of establishing a differential diagnosis for possible causes of knee mechanical blockage. The author reports a case where the patient presented with symptoms of joint blockage, clinically simulating a "bucket handle" lesion on the lateral meniscus. However, at the moment of arthroscopy, no meniscal lesions have been evidenced, with only one localized tumor found behind the posterior cornu of the lateral meniscus, with a free fragment located at the posterior lateral recess. After tumor removal, the patient didn't complain of blockage anymore, and the anatomicopathological diagnosis was PVNS. In our study, four of the seven patients presented with clinical joint blockage, similar to that described by Van Meter⁽¹²⁾. Magnetic resonance imaging was of great value for ruling out a potential meniscal lesion and for verifying the presence of a localized mass at the medial meniscus-capsular union. After resection, as in Van Meter's report⁽¹²⁾, patients no more complained of blockage.

The radiographic study on LPVNS usually does not present changes⁽¹⁰⁾. However, with the advent of magnetic resonance imaging (MRI), the diagnosis has been increasingly accurate. LPVNS presents with a heterogeneous mass at the soft parts, with low sign at T1 and T2 corresponding to a hemosiderin deposit. Despite these findings, MRI cannot be considered as a specific method, being part of a differential diagnosis, the synovial chondromatosis, the synovial hemangioma, the fibroxanthoma, rheumatoid arthritis, and even the synovial sarcoma^(8,13,14).

Some studies report that LPVNS has a lower recurrence rate and a more favorable response to surgical treatment when compared to the diffuse form of PVNS despite its histological similarity(6,8). It can be found in literature that the recurrence of the diffuse form can range from 25% to 50%, while the localized form presents a recurrence rate below 5%^(4,10,11). In this study, the authors present patients with a minimum follow-up period of 12 months, with recurrences not being noted to date, consistent to the low recurrence rate of the localized form, as described in literature. Patient number one on Table 1 reported a clinical history of previous arthroscopic procedure, with recurrence of symptoms 3 months later. Magnetic resonance showed an image that was very similar to that evidenced preoperatively. An arthroscopic review was performed in our medical service, with lesion resection. The patient has been submitted to surgery 30 months ago, with no evidences of recurrence to date. In our point of view, there was an incomplete resection of the lesion in the first procedure, and not a recurrence.

There is a consensus in literature stating that the marginal excision of the LPVNS results in satisfactory outcomes^(1,8,9,13). According to Kim et al.⁽⁸⁾, arthroscopy is a valuable method for LPVNS diagnosis and treatment. Those authors state that the arthroscopic technique is less invasive than the open technique, especially when the lesion is located at the posterior compartment. Eventual associated lesions can be treated by using the same procedure.

CONCLUSION

LPVNS is a rare disease, difficult to diagnose, and, upon clinical suspect, magnetic resonance imaging is the diagnostic method of choice, and it should be requested postoperatively whenever possible. Ultimate diagnosis should be confirmed by an anatomicopathological study.

Despite the small sample, typical of the low incidence of such lesion, the authors believe that the arthroscopic excision of the LPVNS is an efficient method, with a low morbidity rate, which provides the remission of symptoms and a low recurrence rate.

REFERENCES

Received in: 08/11/04; approved in: 11/22/04

Study conducted at the Orthopaedics and Traumatology Department and Institute, Hospital das Clínicas, Medical School of the University of São Paulo, Brazil

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Correspondence to

Rua Barata Ribeiro 414, Cj. 53

São Paulo-SP, BRASIL, CEP 01308-000.

Publication Dates

• Publication in this collection
  27 July 2005
• Date of issue
  2005

History

• Received
  11 Aug 2004
• Accepted
  22 Nov 2004